Acing Acute Care for Elders

At 336-licensed-bed Virginia Mason Medical Center in Seattle, Senior Vice President, Hospital Administrator, and Chief Nursing Officer Charleen Tachibana, RN, MN, FAAN, says a huge problem that led her hospital to create an ACE unit was the negative attitudes some caregivers and the general population had toward seniors, especially more than a decade ago.

"The population in general 12 to 13 years ago had a different attitude about older people—you can think of some of the phrases: old geezer, dirty old man, people who are confused, they dribble or can't feed themselves—and certain impressions formed over time; at times, we carried that into our work.

"But there are psychological and psychosocial reasons that explain these behaviors that can lead to providers managing them or addressing them differently. For example, understanding that there's a high rate of depression and alcoholism among elders who are lonely is an important part of this care.

"Providers need to think in terms of how seniors will get nutrition if they can't get to the grocery store."

In nursing education, she says, there has been no concentrated skill-building effort around care of elders. "It's never been considered a subgroup with unique needs, [one] that physiologically functions differently, like pediatrics. So we had a lot of work to do with our nursing staff." Virginia Mason started first with the Nurses Improving Care for Healthsystem Elders, or NICHE, training model, to educate nurses, therapists, nursing assistants, and social workers on how to deal with the unique needs of the elderly.

Tachibana says Virginia Mason administrators realized "we had to create a physical environment to help support these processes, and we knew we'd need to make staffing changes to better meet those needs."

Susan Abolafya, RN, MN, the director of the Virginia Mason ACE unit, and Kellie Meserve, MN, RN-BC, the unit's clinical leader, say the unit's success in preventing functional decline is also saving money because the hospital's strategies to assess patients and prevent delirium mean it reduces the time patient care technicians, or sitters, need to sit with patients considered unsafe to be alone because they are agitated or restless.

That amounted to about a $73,000 saving in 2011, Abolafya says.

Much of the trick in getting to the root of an elderly person's agitation and delirium requires a kind of detective work to determine whether there might be a physical reason why the patient is in anguish.

Abolafya recalls the very large man, a former athlete with cognitive issues, who became delirious and combative when he came to the floor. He was spewing profanities and grabbing people and was becoming threatening to staff.